Knee Replacement Results Improved By Computer Navigation

Posted on June 19, 2015.

For Immediate Release CONTACT: Amanda Maselli New Hampshire Orthopaedic Center 603.883.0091   KNEE REPLACEMENT ... Read More

Dr. Sinkov – On Call with the NH Medical Society

Posted on May 15, 2015.

If you weren’t able to catch Dr. Sinkov’s May 13th ‘On Call with the NH Medical ... Read More

We Made New Hampshire Magazine’s ‘Top Doc’ List for 2015!

Posted on March 20, 2015.

We are proud to be included in New Hampshire Magazine’s Top Doctors for 2014!  Congratulations ... Read More

New Hampshire Orthopaedic Center

Return to Golf and Tennis After Joint Replacement 

Posted on June 18, 2015.

By: Kathleen A. Hogan, MD

As the last of the snow melts away, thoughts turn away from the ski slopes and towards the golf course and the tennis courts.    Unfortunately, if you have been living with hip or knee pain, these recreational activities may be more painful than pleasurable.    

As a joint replacement surgeon, I treat patients whose pain from arthritis keeps them from participating in activities that they enjoy.  When non-operative treatments no longer provide significant pain relief, joint replacement may be an option.  Hip and knee replacement can be extremely successful in relieving pain from daily activities such as walking, standing, and stair climbing.  But for some people, this is not enough.   They want to get back to playing sports. This article will explore the issues affecting a return to golf and tennis after joint replacement. 

Impact of Activity on an Artificial Joint

Joint replacements can wear out, and high impact activities such as running may cause the artificial joint to wear out faster, possibly leading to further surgery.  However, most joint replacement surgeons allow their patients to resume moderate activity, including golf and doubles tennis.   Golf and tennis do place considerable stresses on the knee with joint reactive forces similar to jogging generated during the swing of a racket or club.   In golf, the leading knee absorbs the most stress, and in tennis the forehand puts more stress on the knees than does a backhand stroke.

Return to Sporting Activity

Return to sporting activity depends on the type of joint replaced. Recovery after a hip replacement is typically faster than after knee replacement.   The direct anterior approach to hip replacement limits muscle damage and speeds recovery.  However, the bone needs to grow into the implant to stabilize it, and I recommend waiting a minimum of 8 weeks before resuming vigorous activities.   Recovery after knee replacement is slower.  More time is needed to recover range of motion and gain strength.  

Impact of Joint Replacement on Athletic Performance

How does joint replacement affect athletic performance? Surveys of small numbers of golfers show small increase in handicap and decreased drive distance.  Most golfers do not walk the course after joint replacement, and instead choose to use a golf cart.  Some notice some mild discomfort during and after playing, but a high percentage of golfers  were able to resume playing the same or increased frequency as before their surgery.  There is limited data on return to play of tennis players, however.

Can I Return to Golf and Tennis After Joint Replacement? 

So, can you return to golf and tennis after joint replacement? The answer is yes.  However, the tennis and golf swings do put considerable force on the joints. It may take time to rehabilitate your muscles to allow you to return to the same level of activity you had before your surgery.  Even after joint replacement your new hip or knee may ache or feel stiff after athletic activity.  However most golfers and tennis players indicate that they are able to continue to enjoy their sports following joint replacement.  If you routinely participate in sporting activities after joint replacement, it is usually recommended that you have an X-ray every 5 years to ensure that there has been no premature wear of the joint. 

What is the Cause of My Hip Pain?

Posted on May 12, 2015.

By: Kathleen A. Hogan, MD

Your hip is hurting. Walking, sleeping, everything seems to cause your hip to hurt. The pain must be coming from your hip joint, correct? Perhaps. Sometimes it can be surprisingly difficult to determine what joint is the primary source of pain.  Hip arthritis can cause back, hip, and knee pain. Arthritis of the spine can cause back, hip, and leg pain. If X-rays show arthritis in multiple areas, how can your physician determine the primary source of pain?

The first step is to pay attention to your symptoms so that you can describe them accurately to your doctor. When do you hurt? All the time or just when you are walking?  Where do you feel pain? Is it down the leg, in the groin, or on the outside of the hip? Do you have numbness or pins and needles in your legs?   Is the pain better when you walk with a shopping cart in the grocery store? Does the pain start after you walk a specific distance? These are some questions that your doctor may ask to help to determine where your pain is originating from.  

Causes of Hip Pain

What are some causes of hip pain? Pain from hip arthritis is typically located in the groin and may radiate down to the knee.  Some patients have limited motion of the hips with difficulty putting on shoes and socks, and pain that is predominately in the back or in the knee.   Bursitis around the hip can cause pain on the outside of the hip.  It can be very painful to sleep on ones side.  Sometimes the hip may feel like it is going to give out.  Disc herniations in the back can cause pain that radiates down the leg. Depending on the location of the disc herniation, the pain may go into the groin. Spinal stenosis is caused by the narrowing of the space for the nerves in the back due to arthritic changes.  This can cause pain that radiates down both legs. Pain from spinal stenosis is often improved when you lean forward (on a shopping cart, for example).  Back and hip pain can often be caused by muscle weakness or tightness as well.  

Diagnosing Hip Pain

In order to help determine the cause of your pain, your doctor may choose to order X-rays of your hip and/or back.  X-rays are very good at showing bony abnormalities and for the diagnosis of arthritis.  Sometimes an MRI can also give helpful information.  MRI’s will show disc herniations, tendon injuries, and bony abnormalities such as avascular necrosis.  However, an abnormal finding on an X-ray or MRI may or may not be the source of your pain.  Cortisone injections can provide pain relief and also help determine if the abnormalities on the imaging studies are causing your pain. Physical therapy is often helpful if muscle imbalance or weakness is contributing to the pain.  Not all pain is arthritis and not all patients with arthritis require surgery.  If you are having hip pain that keeps you from doing things you enjoy, talk to your doctor and get evaluated to find out where the pain is really coming from and what can be done to get you back to doing the activities you enjoy.

Muscle Strain

Posted on March 31, 2015.

By: Daniel P. Bouvier, MD

What is a Muscle Strain?

A strain is an injury to a muscle or tendon, which occurs when the muscle is stretched or torn.  This differs from a sprain, which is a term used to describe a stretching or tearing of ligaments.  Ligaments connect bones to other bones, whereas tendons connect muscles to bones.  Muscle strain often occurs in the low back and the hamstrings.


A “pop” may be felt and there will be some discomfort. There may be more pain when attempting to move the affected area. Swelling may occur. Depending on the strain’s severity, bruising may develop – sometimes days later – and not necessarily at the original painful area.


An acute muscle strain results from a rapid movement of a limb or from a fall.  Lifting with improper body mechanics can also result in a strain. Chronic muscle injuries occur from “micro” trauma from repetitive activity in sports like tennis, gymnastics, golf, and ballet.

Risk Factors

Deconditioning:  The “Weekend Warrior” syndrome can lead to acute injury.  If you are participating in an activity you don’t do regularly or don’t keep in shape to do, you are setting yourself up for a muscle strain.

Uncontrollable elements:  Weather or other factors may result in slippery field conditions.

Equipment:   Faulty, worn, or improper footwear, ski equipment, or other sporting gear.

Fatigue: If you can feel your muscles reaching a fatigue point, your normal protective mechanics will be disrupted and sudden injury may result.

Improper Warm Up:  Improper warm up can lead to injury.  Doing a light to moderate period of jogging or cardio activity can warm the muscles for proper stretching prior to your activity.


The history and a good physical exam is usually enough to diagnose a muscle strain.  A screening X-ray is often used to rule out a bone avulsion, or fracture of the bone at the attachment point of the muscle, which is more commonly seen in children.  In severe cases an MRI can be useful, but isn’t always necessary.

When to See a Specialist

If a loud pop is heard during an injury, followed by severe pain, inability to move the limb, and/or an inability to bear weight on the extremity, orthopaedic evaluation is usually necessary.  Severe bruising is another reason to seek out specialty care.


Treatment may range from basic home remedies all the way to surgery, depending on the severity of the injury.

RICE: Rest, Ice, Compression, Elevation is usually the first step in muscle strain treatment.  Over the counter medications to control pain may be useful, but only on an as needed basis.  Rest doesn’t necessarily mean to do nothing.  One can cross train and do activities such as a bike or using the pool, that won’t aggravate or worsen symptoms.   Proper elevation means to elevate the injured area above the level of the heart.  Icing should be done for 15-20 minutes at a time 4-5 times daily, taking care to place a layer between the skin and the ice so as not to cause a frostbite injury to the skin.  After a few days of RICE, it is usually safe and recommended to begin to move the limb as your symptoms will allow.

Physical Therapy: Many strains and sprains are very amenable to physical therapy.  A good physical therapist can be instrumental in speeding your recovery by helping to reduce swelling, reactivate muscles and keep other joints moving.

Surgery:   In the most severe cases in certain parts of the body, surgery may be warranted or offered as an option to reattach or repair a disrupted muscle/tendon unit.

Traveling After Joint Replacement: Questions Answered

Posted on March 23, 2015.

By: Kathleen A. Hogan, MD

When can I travel? Will my new hip replacement set off metal detectors at the airport? Can I get a card to prove that I had my knee replaced? These are common questions of patients are planning on traveling after joint replacement.

Security Screening When Traveling After Joint Replacement

Hip and knee replacements are made of metal and will be detected by most metal detectors at airports and other security screening stations. Prior to the terrorist attacks of 2001, airline screeners would accept a card or physician note stating that a metal implant had been placed and no additional screening was needed. That is no longer the case. The TSA will not accept any card as proof of a joint replacement. If a metal detector is set off, additional screening will be required.

The use of full body X-ray scanners at most airports in the United States has made travel much easier for the millions of travelers with metal implants. Although the metal implant will be picked up by the X-ray scanner, it will be clear that the metal is in the bone. Occasionally, a simple pat down of the body part is done, but the screening process is much less time consuming than it was previously. Additionally, people with pacemakers or other implanted electronic devices who used to have to bypass the metal detector and be screened by hand now can usually pass safely through the X-ray scanner.

Recommendations for Safely Traveling After Joint Replacement

It is safe to travel after a hip or knee replacement. If the surgery was done within the last 6 weeks, you should discuss with your surgeon if any particular treatment for the prevention of blood clots is recommended. Recent surgery is a risk factor for blood clots as is prolonged sitting, and dehydration; make sure to drink water on your flight. For flights longer than 4 hours in duration, I recommend getting out of your seat and moving around the aircraft every few hours. Compression stockings can help prevent swelling in your legs and decrease the risk of blood clots. Taking aspirin before and after a long flight may also decrease this risk. However, if you have had a prior blood clot, have a family history of blood clots, are taking birth control pills or hormone replacement medications, have had recent surgery or have cancer, you may be at much higher risk. Sometimes prescription anticoagulants are recommended for individuals at high risk of blood clots. If you have any concerns, be sure to talk to your doctor before your flight.

Most major airports are large and much walking is required to get from the terminal entrance to your gate. If you walk with a cane or walker or have cardiac or pulmonary problems that limit your ability to walk long distances, consider asking for wheelchair assistance. You do not need a physicians note to take advantage of this service. This can help you to arrive at your destination without being exhausted from airport travel.

I hope this article has answered many of your questions about traveling after joint replacement. Enjoy your trip and don’t forget to talk to your doctor before your trip if you have any concerns!

Why Weight Matters: Obesity and Knee Replacement

Posted on March 17, 2015.

By: Kathleen A. Hogan, MD

Obesity and knee replacement are closely linked. It is well established that people who are overweight have an increased incidence of knee arthritis at a younger age and are more likely to require knee replacement. Joint pain can limit mobility and diminish exercise tolerance which may contribute to weight gain.

What is BMI?

The relationship between height and weight is determined by a mathematical calculation to give a body mass index (BMI). A BMI of 20-25 is considered to be ideal. A person with a BMI above 30 is considered to be obese and over 40 is morbidly obese. For example, a 5’7’’ 145 lb woman would have a BMI of 23 (normal body weight). If her weight increased to 200 her BMI would be 31 (obese). At a weight of 250, her BMI would be 40 (morbidly obese). BMI helps physicians standardize our discussion of weight. However it does not take into account the distribution of that weight – the apple or pear shaped body shapes for example. Nor does it determine if weight is primarily muscle or fat.

Risks of Obesity and Knee Replacement

Why does weight matter when discussing joint replacement? Patients who are excessively overweight are at much higher risk of compilations following hip or knee replacement surgery. The risk of infection, for example rises exponentially as BMI increases over 40. The risk of a major infection after knee replacement is less than 1% in patients with a BMI of 20-25. This risk rises to 1-2% in obese patients (BMI >30), 3-4% in morbidly obese patients (BMI >40) and in a patient with a BMI of 50 the risk is over 8% This increased risk is independent of other medical problems such as diabetes, hypertension, and cardiac disease. Infection after a joint replacement can be a devastating problem. Often, the metal implants must be temporarily removed in order to eradicate the infection. Prolonged treatment with IV antibiotics is required. Only after the infection has been successfully treated can a new joint be put back in place. Elevated body weight also increases the risk of medial complications, blood clots, and even death following surgery. Diabetes, smoking, and poor nutrition are also risk factors for complications following surgery.

What Criteria Are Used?

Every surgeon has his or her criteria for determining if a patient is “too big” for a joint replacement. Body weight and BMI are important; however other heath problems such as diabetes, smoking, malnutrition, peripheral vascular disease, and the condition of the legs’ skin are also important considerations in determining if surgery can be safely performed. It is very difficult to explain to someone that their disabling arthritic pain can not be safely treated with a joint replacement because of their body weight. Joint replacement surgery can be a life altering procedure when successful, with improvement in mobility and elimination of pain. However, the complications of joint replacement can be devastating as well. If a surgeon tells you that weight loss is necessary prior to surgery, it is only because the risks of surgery outweigh the potential benefits. Loosing weight prior to knee replacement will not only improve the outcome of your surgery and lower the risk of major complications, but will also have life-long health benefits.